Tonsillitis Nursing Diagnosis and Nursing Care Plan

Tonsillitis Nursing Care Plans Diagnosis and Interventions

Tonsillitis NCLEX Review and Nursing Care Plans

Tonsillitis refers to the inflammation of the palatine tonsils and is typically caused by a viral infection.

The tonsils are lumps of soft tissues found at the back of the throat. The palatine tonsils are a pair of tonsils positioned on each side of the oropharynx.

They play a role in the body’s immune system. With their location, they can block opportunistic microorganisms from entering the body through the mouth and nose.

Tonsillitis is a common condition. It is frequently seen in children aged 5 to10 years and in young adults between 15 and 25 years.

However, tonsillitis can occur at any age.

Signs and Symptoms of Tonsillitis

  • Sore throat – commonly the first symptom noted in tonsillitis; the tonsils and the surrounding organs swell causing pain and sore throat
  • Swelling of the tonsils – due to the inflammatory response from infection
  • Erythema – the tonsils turn red in colour with yellowish coating or patches
  • Dysphagia – difficulty swallowing occurs due to the swollen tonsils; food and drink are not be able to pass through the throat easily
  • Swollen and painful lymph nodes in the neck- the lymph nodes, as part of the immune system, react to the infection; may feel tender upon palpation
  • Fever – occurs as the body’s response to the infection process
  • Headache
  • Loss of appetite – the general unwell feeling caused by tonsillitis together with dysphagia can cause loss of appetite
  • Fatigue – the decline in oral fluid and food intake can reduce energy causing easy fatiguability
  • Bad breath – caused by the presence of bacteria in the mouth

Causes of Tonsillitis

Tonsillitis is commonly caused by viral infection.

Common viruses such as rhinoviruses, enteroviruses, and influenza viruses can cause tonsillitis.

In bacterial cases, Group A Streptococcus are the common causes.

Risk factors have been identified to predispose a person to develop tonsillitis. They are as follows:

  • Young age. Tonsillitis commonly occurs in children due to their immature immune system.
  • Frequent exposure to germs. Frequent close contact with other people is a risk factor as the chances of infection being transferred is always present.

Complications of Tonsillitis

Tonsillitis can be acute or chronic. When the infection is frequently recurring, the chance of complications from developing is quite high.

  1. Obstructive sleep apnea. Due to the position of the tonsils, their swollen state can block the airway. This happens particularly when a person assumes prone position, such as when sleeping.
  2. Tonsillar cellulitis. Infection can spread to surrounding tissues causing tonsillar cellulitis.
  3. Peritonsillar abscess. In some cases, infection can cause pus production which then collects behind the tonsils.
  4. Strep infection. In some cases of tonsillitis caused by bacterial infection, other strep infection can occur, which can lead to:
    • Rheumatic fever. Rheumatic fever is a serious inflammatory condition caused by inadequately treated tonsillitis or scarlet fever. It can affect the heart, joints, the nervous system, and the skin.
    • Poststreptococcal glomerulonephritis. This is a rare condition involving the inflammation of the kidneys due to a streptococcus infection. The best way to avoid this condition is to treat any other streptococcus infection.
    • Poststreptococcal reactive arthritis. This is a condition involving arthritis of just one joint associated with a recent streptococcus infection.

Diagnosis of Tonsillitis

  •  History taking and physical examination – include the following:
    • Inspection of the tonsils by shining a torch into the throat with the mouth wide open
    • Inspection of the nose and ears to check for any other possible sites of infection.
    • Inspection of the skin for any rash related to scarlet fever to rule out the condition
    • Palpation of the lymph nodes around the neck
    • Auscultation to listen to the patient’s breathing and heart sounds.

In some cases, mononucleosis may be ruled out as it can also cause inflammation of the tonsils.

Other diagnostic tests may be performed as follow:

  • Throat swab – a sterile swab rubbed over the throat will be sent to the lab to check for streptococcal bacteria and the need for antibiotics
  • Complete blood count – to show the presence of either a viral or bacterial infection depending on what blood cell is elevated

Treatment for Tonsillitis

  1. At-home management. Most cases of viral tonsillitis are treated by bed rest and adequate hydration. The following are helpful interventions to promote comfort at home:
  2. Warm and cold treats can both soothe a sore throat.
  3. Saltwater gargle. A solution of half a teaspoon of salt in a glass of water as a gargle can help provide relief to sore throat.
  4. Lozenges for sore throat
  5. Pain relievers
  6. Antibiotics. In cases of bacterial causes of tonsillitis, a full course of antibiotics is prescribed. The full course must be taken as directed as inadequately treated tonsillitis can cause serious complications.
  7. Tonsillectomy. Surgery to remove tonsils may be recommended in some cases of recurring tonsillitis. This can also be suggested if the condition is not responding to antibiotic treatment. A frequent tonsillitis can be defined as:
  8. Seven episodes of tonsillitis or more in the preceding year
  9. At least five episodes a year in the past two years
  10. At least three episodes a year in the past three years.

Surgery can also be the treatment of choice if the tonsillitis is causing difficult to manage complications such as apnea, swallowing difficulty, and abscess formation. 

Tonsillitis Nursing Diagnosis

Nursing Care Plan for Tonsillitis 1

Hyperthermia secondary to infective process of tonsillitis as evidenced by temperature of 38.5 degrees Celsius, rapid breathing, profuse sweating, and chills

Desired Outcome: Within 4 hours of nursing interventions, the patient will have a stabilized temperature within the normal range.

Nursing Intervention for TonsillitisRationales
Assess the patient’s vital signs at least every 4 hours.To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the antibiotics and antipyretic drugs administered.
Remove excessive clothing, blankets, and linens. Adjust the room temperature.To regulate the temperature of the environment and make it more comfortable for the patient.
Administer the prescribed antibiotic and anti-pyretic medications.Use the antibiotic to treat bacterial infection (tonsillitis), which is the underlying cause of the patient’s hyperthermia. Use the fever-reducing medication to stimulate the hypothalamus and normalize the body temperature.
Offer a tepid sponge bath.To facilitate the body in cooling down and to provide comfort.
Elevate the head of the bed.Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively.

Nursing Care Plan for Tonsillitis 2

Nursing Diagnosis: Risk for Infection

Desired Outcome: The patient will be able to avoid the development of worsening infection.

Nursing Intervention for TonsillitisRationales
Assess vital signs and observe for any signs of infection as well as for any signs of respiratory distress.To assess for the evidence of ongoing infection. Tonsillitis may cause blockage of airways, which may lead to respiratory distress.
Perform a focused assessment on the oropharyngeal region, particularly checking for any collection of abscess.Tonsillitis can lead to peritonsillar abscess. The infection can cause pus production which then collects behind the tonsils.  
Prepare the patient for tonsillectomy.Surgery can be the treatment of choice if the tonsillitis is causing difficult to manage complications such as apnea, swallowing difficulty, and abscess formation. 
Teach the patient how to perform proper hand hygiene.To maintain patient safety and reduce the risk for cross contamination.
Administer antibiotics as prescribed.To treat the underlying infection with broad spectrum antibiotics, then switch with the type of antibiotics to which the causative bacteria are sensitive. This is also done to prevent the risk of developing further infection in a patient with bacterial tonsillitis.

Nursing Care Plan for Tonsillitis 3

Nursing Diagnosis: Acute Pain related to inflammation of the tonsils as evidenced by  pain score of 8 out of 10, painful and difficult swallowing (dysphagia)

Desired Outcome: The patient will demonstrate relief of pain as evidenced by a pain score of 0 out of 10, stable vital signs, and absence of restlessness.

Nursing Intervention for TonsillitisRationale
Administer prescribed pain medications.To alleviate the symptoms of acute pain.  
Assess the patient’s vital signs and characteristics of pain at least 30 minutes after administration of medication.  To monitor effectiveness of medical treatment for the relief of abdominal pain. The time of monitoring of vital signs may depend on the peak time of the drug administered.  
Elevate the head of the bed and position the patient in semi Fowler’s.To increase the oxygen level by allowing optimal lung expansion.

Nursing Care Plan for Tonsillitis 4

Ineffective Airway Clearance related to inflammation of tonsils as evidenced by difficulty of swallowing and shortness of breath

Desired Outcome: The patient will be able to maintain airway patency and improved airway clearance as evidenced by respiratory rates between 12 to 20 breaths per minutes, oxygen saturation within the target range (as set by the physician), and verbalize ease of breathing.

Nursing Intervention for TonsillitisRationales
Assess the patient’s vital signs and characteristics of respirations at least every 4 hours. Assess for signs of hypoxia.To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment.  Early signs of hypoxia include irritability, confusion, headache, restlessness, and pallor.
Place the patient on a side-lying or prone position.To promote drainage of saliva from the mouth through gravity, while preventing aspiration, especially in children.
Suction secretions.To help clear thick secretions that the patient is unable to expectorate.
Administer the prescribed medications (e.g. corticosteroids) and antibiotic medications.Steroids: To reduce the edema in the pharynx. Antibiotics: If there is any bacterial infection that is causing the inflammation
Elevate the head of the bed and assist the patient to assume semi-Fowler’s position.Head elevation and proper positioning help improve the expansion of the lungs, enabling the patient to breathe more effectively.

More Nursing Diagnosis for Tonsillitis

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines and policies and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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